Impact of genetic and non-genetic factors on phenotypic diversity in NBAS-associated disease

Biallelic pathogenic variants in neuroblastoma-amplified sequence (NBAS) cause a pleiotropic multisystem disorder. Three clinical subgroups have been defined correlating with the localisation of pathogenic variants in the NBAS gene: variants affecting the C-terminal region of NBAS result in SOPH syndrome (short stature, optic atrophy, Pelger-Huët anomaly), variants affecting the Sec 39 domain are associated with infantile liver failure syndrome type 2 (ILFS2) and variants affecting the ß-propeller domain give rise to a combined phenotype. However, there is still unexplained phenotypic diversity across the three subgroups, challenging the current concept of genotype-phenotype correlations in NBAS-associated disease. Therefore, besides examining the genetic influence, we aim to elucidate the potential impact of pre-symptomatic diagnosis, emergency management and other modifying variables on the clinical phenotype. We investigated genotype-phenotype correlations in individuals sharing the same genotypes (n = 30 individuals), and in those sharing the same missense variants with a loss-of-function variant in trans (n = 38 individuals). Effects of a pre-symptomatic diagnosis and emergency management on the severity of acute liver failure (ALF) episodes also were analysed, comparing liver function tests (ALAT, ASAT, INR) and mortality. A strong genotype-phenotype correlation was demonstrated in individuals sharing the same genotype; this was especially true for the ILFS2 subgroup. Genotype-phenotype correlation in patients sharing only one missense variant was still high, though at a lower level. Pre-symptomatic diagnosis in combination with an emergency management protocol leads to a trend of reduced severity of ALF. High genetic impact on clinical phenotype in NBAS-associated disease facilitates monitoring and management of affected patients sharing the same genotype. Pre-symptomatic diagnosis and an emergency management protocol do not prevent ALF but may reduce its clinical severity.

Father-to-daughter transmission in late-onset OTC deficiency: an underestimated mechanism of inheritance of an X-linked disease

BACKGROUND

Ornithine Transcarbamylase Deficiency (OTCD) is an X-linked urea cycle disorder characterized by acute hyperammonemic episodes. Hemizygous males are usually affected by a severe/fatal neonatal-onset form or, less frequently, by a late-onset form with milder disease course, depending on the residual enzymatic activity. Hyperammonemia can occur any time during life and patients could remain non- or mis-diagnosed due to unspecific symptoms. In heterozygous females, clinical presentation varies based on the extent of X chromosome inactivation. Maternal transmission in X-linked disease is the rule, but in late-onset OTCD, due to the milder phenotype of affected males, paternal transmission to the females is possible. So far, father-to-daughter transmission of OTCD has been reported only in 4 Japanese families.

RESULTS

We identified in 2 Caucasian families, paternal transmission of late-onset OTCD with severe/fatal outcome in affected males and 1 heterozygous female. Furthermore, we have reassessed the pedigrees of other published reports in 7 additional families with evidence of father-to-daughter inheritance of OTCD, identifying and listing the family members for which this transmission occurred.

CONCLUSIONS

Our study highlights how the diagnosis and pedigree analysis of late-onset OTCD may represent a real challenge for clinicians. Therefore, the occurrence of paternal transmission in OTCD should not be underestimated, due to the relevant implications for disease inheritance and risk of recurrence.

The impact of liver transplantation on health-related quality of life in (acute) intoxication-type inborn errors of metabolism

Organic acidurias (OAs), urea-cycle disorders (UCDs), and maple syrup urine disease (MSUD) belong to the category of intoxication-type inborn errors of metabolism (IT-IEM). Liver transplantation (LTx) is increasingly utilized in IT-IEM. However, its impact has been mainly focused on clinical outcome measures and rarely on health-related quality of life (HRQoL). Aim of the study was to investigate the impact of LTx on HrQoL in IT-IEMs. This single center prospective study involved 32 patients (15 OA, 11 UCD, 6 MSUD; median age at LTx 3.0 years, range 0.8-26.0). HRQoL was assessed pre/post transplantation by PedsQL-General Module 4.0 and by MetabQoL 1.0, a specifically designed tool for IT-IEM. PedsQL highlighted significant post-LTx improvements in total and physical functioning in both patients' and parents' scores. According to age at transplantation (≤3 vs. >3 years), younger patients showed higher post-LTx scores on Physical (p = 0.03), Social (p < 0.001), and Total (p =0.007) functioning. MetabQoL confirmed significant post-LTx changes in Total and Physical functioning in both patients and parents scores (p ≤ 0.009). Differently from PedsQL, MetabQoL Mental (patients p = 0.013, parents p = 0.03) and Social scores (patients p = 0.02, parents p = 0.012) were significantly higher post-LTx. Significant improvements (p = 0.001-0.04) were also detected both in self- and proxy-reports for almost all MetabQoL subscales. This study shows the importance of assessing the impact of transplantation on HrQoL, a meaningful outcome reflecting patients' wellbeing. LTx is associated with significant improvements of HrQol in both self- and parent-reports. The comparison between PedsQL-GM and MetabQoL highlighted that MetabQoL demonstrated higher sensitivity in the assessment of disease-specific domains than the generic PedsQL tool.

Natural history of epilepsy in argininosuccinic aciduria provides new insights into pathophysiology: A retrospective international study

OBJECTIVE

Argininosuccinate lyase (ASL) is integral to the urea cycle, which enables nitrogen wasting and biosynthesis of arginine, a precursor of nitric oxide. Inherited ASL deficiency causes argininosuccinic aciduria, the second most common urea cycle defect and an inherited model of systemic nitric oxide deficiency. Patients present with developmental delay, epilepsy, and movement disorder. Here we aim to characterize epilepsy, a common and neurodebilitating comorbidity in argininosuccinic aciduria.

METHODS

We conducted a retrospective study in seven tertiary metabolic centers in the UK, Italy, and Canada from 2020 to 2022, to assess the phenotype of epilepsy in argininosuccinic aciduria and correlate it with clinical, biochemical, radiological, and electroencephalographic data.

RESULTS

Thirty-seven patients, 1-31 years of age, were included. Twenty-two patients (60%) presented with epilepsy. The median age at epilepsy onset was 24 months. Generalized tonic-clonic and focal seizures were most common in early-onset patients, whereas atypical absences were predominant in late-onset patients. Seventeen patients (77%) required antiseizure medications and six (27%) had pharmacoresistant epilepsy. Patients with epilepsy presented with a severe neurodebilitating disease with higher rates of speech delay (p = .04) and autism spectrum disorders (p = .01) and more frequent arginine supplementation (p = .01) compared to patients without epilepsy. Neonatal seizures were not associated with a higher risk of developing epilepsy. Biomarkers of ureagenesis did not differ between epileptic and non-epileptic patients. Epilepsy onset in early infancy (p = .05) and electroencephalographic background asymmetry (p = .0007) were significant predictors of partially controlled or refractory epilepsy.

SIGNIFICANCE

Epilepsy in argininosuccinic aciduria is frequent, polymorphic, and associated with more frequent neurodevelopmental comorbidities. We identified prognostic factors for pharmacoresistance in epilepsy. This study does not support defective ureagenesis as prominent in the pathophysiology of epilepsy but suggests a role of central dopamine deficiency. A role of arginine in epileptogenesis was not supported and warrants further studies to assess the potential arginine neurotoxicity in argininosuccinic aciduria.

Neurologic outcome following liver transplantation for methylmalonic aciduria

Liver and liver/kidney transplantation are increasingly used in methylmalonic aciduria, but little is known on their impact on CNS. The effect of transplantation on neurological outcome was prospectively assessed in six patients pre- and post-transplant by clinical evaluation and by measuring disease biomarkers in plasma and CSF, in combination with psychometric tests and brain MRI studies. Primary (methylmalonic- and methylcitric acid) and secondary biomarkers (glycine and glutamine) significantly improved in plasma, while they remained unchanged in CSF. Differently, biomarkers of mitochondrial dysfunction (lactate, alanine, and related ratios) significantly decreased in CSF. Neurocognitive evaluation documented significant higher post-transplant developmental/cognitive scores and maturation of executive functions corresponding to improvement of brain atrophy, cortical thickness, and white matter maturation indexes at MRI. Three patients presented post-transplantation reversible neurological events, which were differentiated, by means of biochemical and neuroradiological evaluations, into calcineurin inhibitor-induced neurotoxicity and metabolic stroke-like episode. Our study shows that transplantation has a beneficial impact on neurological outcome in methylmalonic aciduria. Early transplantation is recommended due to the high risk of long-term complications, high disease burden, and low quality of life.

Patients with systemic lupus erythematosus and their experience with vaccination against COVID-19: a descriptive and explanatory study

Not available

AB0455 DRUGS, AUTOANTIBODIES AND GENES CONTRIBUTE TO THE DEVELOPMENT OF CHRONIC DAMAGE IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS

Background

Genetic contribution to development of chronic damage have been scarcely investigated in systemic lupus erythematosus (SLE). In fact, whereas most studies have looked for an association between genetic variants and SLE susceptibility or disease phenotypes, only few have focused on the relationship between these biomarkers and damage development.

Objectives

Moving from these premises, we firstly analyzed the distribution of organ damage in a cohort of SLE patients and secondly we evaluate the role of clinical and genetic factors in determining the development of chronic damage.

Methods

Caucasian SLE patients, diagnosed according with 1997 ACR criteria, were enrolled, and clinical and laboratory data were collected. Based on literature data, we selected a panel of 17 SNPs of following genes STAT4, IL10, IRAK1, HCP5, MIR146a, ATG16L1, IRGM, ATG5, MIR124, MIR1279, TNFSF4, CD40. Genotyping was performed by allelic discrimination assays. A phenotype-genotype correlation analysis was performed by evaluating specific domains of SLICC Damage Index (SDI).

Results

Among 175 Caucasian SLE patients, 105 (60%) exhibited damage (SDI ≥1) with a median value of 1.0 (IQR 3.0). The musculoskeletal (26.2%), neuropsychiatric (24.6%) and ocular domains (20.6%) were involved most frequently. The presence of damage was associated with higher age, longer disease duration, neuropsychiatric (NP) manifestations, anti-phospholipid syndrome and the positivity of anti-dsDNA antibodies. Concerning therapies cyclophosphamide, mycophenolate mofetil and glucocorticoids resulted associated with the development of damage. The genotype/phenotype correlation analysis showed an association between renal damage, identified in 6.9% of patients, and rs2205960 of TNFSF4 (p=0.001; OR 17.0). This SNP resulted significantly associated with end-stage renal disease (p= 0.018, OR 9.68) and estimated GFR<50% (p=0.025, OR 1.06, Figure 1). The rs1463335 of MIR1279 gene was associated with the development of NP damage (p=0.029; OR 2.783). The multivariate logistic regression analysis confirmed the associations between TNFSF4 rs2205960 SNP and renal damage (p=0.020, r=2.53) and between NP damage and rs1463335 of MIR1279 gene (p=0.013, r=1.26)].

Figure 1.

Association between renal damage and rs2205960 of TNFSF4 (p=0.001). In addition, this SNP resulted significantly associated with the development of two specific items of SDI renal domain: estimated glomerular filtration rate (GFR) <50% and end-stage renal disease (ESRD) (p=0.025, p=0.018 respectively).

Conclusion

We showed the role of age, drugs, and autoantibody profile in determining chronic damage.

Our data suggest a possible role of genetic background in determining the development of renal and neuropsychiatric damage, as demonstrated by the association with polymorphisms of TFNSF4 and MIR1279, respectively. These results agree with previous studies suggesting the involvement of TNFSF4 in Lupus nephritis and microRNA in neuroinflammation.

Disclosure of Interests

None declared

POS1058 BIOLOGICAL DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS IN PSORIATIC ARTHRITIS: PREDICTORS OF TREATMENT SURVIVAL IN A REAL-LIFE SETTING

Background

Psoriatic arthritis (PsA) is a chronic, immune-mediated, inflammatory arthropathy, distinctively involving joints and enthesis. The improved understanding of PsA pathogenesis has enabled the development of biological disease-modifying anti-rheumatic drugs (bDMARDS) targeting specific cytokines and signalling pathways. The availability of these drugs deeply modified PsA history, by preventing disease progression and by improving quality of life. Nevertheless, bDMARDS are not effective in all the patients who may experience primary or secondary inefficacy or adverse events development.

Objectives

In a real-life scenario, we evaluated the bDMARDs retention rate in a large PsA cohort. In detail, we compared drug survival of the first and second biological drug and we investigated the presence of factors associated with the bDMARDs treatment withdrawal.

Methods

We longitudinally evaluated adult PsA patients (2016 CASPAR criteria) treated with at least one bDMARD during disease history. For each PsA patient, the clinical and laboratory data, including demographics, past medical history with the date of diagnosis and treatments, clinical disease phenotypes, were collected in a standardized, computerized and electronically filled form. The retention rate was estimated by using the Kaplan-Meier method. Predictors for bDMARDs withdrawal were investigated in univariate and multivariate Cox proportional hazards analysis, adjusted for relevant variables.

Results

The present analysis included 223 PsA patients [M/F 91/132; median age 57 years (IQR 17); median disease duration 120 months (IQR 132)]. Adalimumab and Etanercept were the most frequently prescribed bDMARDs (41.5% and 41.0%, respectively). The retention rate of the first prescribed bDMARD as reported in Figure 1A: in detail, we found a 12-months retention rate of 79.8%. The comparison between etanercept and adalimumab showed a similar 12-months retention rate, but significantly higher for etanercept at 24 months (82.4% versus 69.5%, p=0.0034, Figure 1B). Out of 223 enrolled PsA patients, 109 (48.9%) received only one bDMARDs, while the remaining 114 (51.1%) received at least 2 drugs. When comparing these two groups of patients, drug survival at 24 months was significantly higher in patients treated with one bDMARD in comparison with those treated with at least two drugs (67.7% versus 52.2%, p=0.03, Figure 1C). Finally, female sex and anxiety-depressive disorders were significantly associated with the treatment with at least two dDMARDs (p=0.005 and p=0.01, respectively).

Conclusion

The results of the present study demonstrated a higher retention rate in the first-line bDMARDs treatment in comparison with second-line. Female sex and anxiety-depressive disorders may negatively affect drug retention rate.

Disclosure of Interests

None declared

AB0436 EFFECTIVENESS OF BELIMUMAB IN SYSTEMIC LUPUS ERYTHEMATOSUS PATIENTS: A REAL-LIFE ANALYSIS

Background

Efficacy and safety of belimumab (BLM) in Systemic Lupus Erythematosus (SLE) patients with active disease have been demonstrated by RCTs [1,2] and confirmed by several observational studies [3-8]. Most of these data have been obtained by the use of BLM intravenous formulation (IV); on the contrary, very few findings are available on the use of the drug subcutaneous formulation (SC).

Objectives

Efficacy and drug survival of BLM have been assessed in a monocentric cohort of SLE patients, exploring any difference between the two routes of administration, IV or SC.

Methods

A longitudinal study on SLE patients (according to ACR 1997 classification criteria [9]) candidates for treatment with BLM has been performed. Demographic, clinical-laboratory and therapeutic data - including glucocorticoid dosage in prednisone-equivalent - have been collected. Disease activity has been assessed by SLEDAI-2k [10]; in patients with inflammatory articular involvement, DAS28-PCR [11] has been used. In compliance with the study protocol, patients were assessed at baseline and at 3 and 12 months after starting treatment.

Results

A total of 85 patients treated with BLM were enrolled, most of whom were female (male/female 2/83), with a median age of 48 years (IQR 13) and a median disease duration of 127 months (IQR 151). Fifty-one patients (60%) were treated with IV formulation and the remaining 34 (40%) with SC route. BLM was prescribed due to the following clinical manifestations: joint involvement (61.2%), cutaneous manifestations (20.0%), renal involvement (for residual proteinuria, 5.9%), haematological modifications (5.9%), constitutional involvement (3.5%), pericarditis (1.2%), headache (1.2%). In both the formulations, joint involvement was the most frequent indication of BLM (IV: 64.7%, SC: 58.8%). Median treatment duration was 15 months (IQR 24). Moving on drug efficacy, after 3 and 12 months of follow-up BLM has determined a significant reduction of SLEDAI-2k median values (p=0.001, p<0.001 respectively, Figure 1A) as well as of daily prednisone dose (p=0.009, p<0.0001 respectively, Figure 1B). In patients treated because of musculoskeletal manifestations, DAS28-PCR reduced significantly at 3 and 12 months after treatment (p<0.0001). Drug survival at 12 months was 70% in the total cohort (Figure 1C) and was higher in patients treated with SC formulation than with IV route (75.8% versus 66.5%, p=ns). During the period of follow-up, 39 patients (45.9%) discontinued BLM: 38.4% of patients due to adverse events, 41% for primary or secondary inefficacy, 15% lost to follow-up, 5.1% for pregnancy. BLM withdrawal for adverse events was more frequent in the group of patients treated with IV formulation than SC one (25.9% versus 5.9%, p=0,0001). 11 patients switched from IV formulation to SC one after a median period of 40 months (IQR 20) without loss of efficacy or adverse events.

Conclusion

Our results confirm BLM efficacy also in a real-life setting. Notably, our data highlight a better drug survival in patients treated with SC formulation, mainly secondary to a less frequency of adverse events.

References

[1]Furie R et al. Arthritis Rheum. 2011;63(12):3918-3930.

[2]Navarra SV et al. Lancet. 2011;377(9767):721-731.

[3]Andreoli L et al. Isr Med Assoc J. 2014;16(10):651-653.

[4]Hui-Yuen JS et al. J Rheumatol. 2015;42(12):2288-2295.

[5]Collins CE et al. Lupus Sci Med. 2016;3(1):e000118.

[6]Touma Z et al. Rheumatol Int. 2017;37(6):865-873.

[7]Iaccarino L et al. Arthritis Care Res (Hoboken). 2017;69(1):115-123.

[8]Gatto M et al. Arthritis Rheumatol. 2020;72(8):1314-1324.

[9]Hochberg M.C. Arthritis Rheum. 1997;40:1725.

[10]Gladman DD et al. J Rheumatol. 2002;29(2):288-291.

[11]Prevoo ML et al. Arthritis Rheum. 1995;38(1):44-48.

Disclosure of Interests

None declared

POS0553 NEW BIOMARKERS IN RHEUMATOID ARTHRITIS: ROLE OF HOMOCYSTEINYLATED ANTI-ALPHA1 ANTITRYPSIN ANTIBODIES

Background

Rheumatoid Arthritis (RA) is a multifactorial, chronic, systemic, inflammatory disease that can lead to progressive joint destruction (Alamanos et al, Autoimmun Rev 2005). Positivity for Rheumatoid Factor (RF) and antibodies against citrullinated proteins (ACPA) is useful for diagnostic and prognostic purposes. Nevertheless, in about 20% of patients, it is not possible to detect the presence of these autoantibodies. This has led to the identification of new antibody specificities, such as antibodies directed against carbamylated proteins (Mastrangelo A et al, J Immunol Res 2015) and, more recently, against homocysteinylated alpha 1 antitrypsin (anti-HATA) (Colasanti T et al, J Autoimmun 2020).

Objectives

To evaluate the prevalence of anti-HATA in a large cohort of patients with RA and their correlation with serological, clinical and erosive bone damage assessed by musculo-skeletal ultrasound (US).

Methods

Consecutive outpatients with RA, diagnosed according to the 2010 ACR/EULAR criteria, were enrolled. Demographic and clinical-laboratory data were recorded, including FR and ACPA determination. Disease activity was assessed by DAS28. The presence of anti-HATA antibodies was investigated by homemade ELISA using native alpha 1 antitrypsin modified in vitro to obtain homocysteinylated alpha 1 antitrypsin. US assessment was performed at the level of bilateral metacarpophalangeal and proximal interphalangeal joints; the presence of erosions and inflammatory features was identified according to OMERACT definitions (Wakefield RJ et al, J Rheumatol 2005).

Results

The present analysis included 91 RA patients (M/F 22/69; mean age 62 years; mean disease duration 12.5 years). Overall, the prevalence of anti-HATA was 69.2%. Anti-HATA antibodies were found in 63/91 (69.2%) of the entire patient cohort, whereas 68/91 (74.3%) patients were positive for ACPA and 63/91 (69.4%) for FR. 41.4% of patients had concomitant positivity for the three autoantibodies (FR, ACPA, anti-HATA). The analysis of patients with triple positivity for related arthritis antibodies (FR, ACPA, anti-HATA) was particularly interesting: indeed, in this subgroup, 80% of patients presented erosive damage, compared to 42.1% of patients who did not present simultaneously the three autoantibodies (p=0.0001). Patients with simultaneous positivity for RF, ACPA and anti-HATA showed a more aggressive disease phenotype (p=0.0001). Finally, a positive correlation was also found between disease activity (expressed by DAS28) and total inflammatory and erosive ultrasonographic score (p=0.005 and p=0.001, respectively).

Conclusion

The results of the present study confirm a high prevalence of anti-HATA in RA patients; furthermore, patients with concomitant presence of anti-HATA, ACPA and RF showed a more aggressive disease phenotype, in terms of erosive damage. Our analysis underlines as the characterization of new antibody specificities in RA could help in the early diagnosis of this disease and in the characterization of the different severity degrees.

References

[1]Alamanos Y, Drosos AA. Epidemiology of adult rheumatoid arthritis. Autoimmun Rev. 2005 Mar;4(3):130-6.

[2]Mastrangelo A, Colasanti T, Barbati C, Pecani A, Sabatinelli D, Pendolino M, Truglia S, Massaro L, Mancini R, Miranda F, Spinelli FR, Conti F, Alessandri C. The Role of Posttranslational Protein Modifications in Rheumatological Diseases: Focus on Rheumatoid Arthritis. J Immunol Res. 2015;2015:712490;

[3]Colasanti T, Sabatinelli D, Mancone C, Giorgi A, Pecani A, Spinelli FR, Di Giamberardino A, Navarini L, Speziali M, Vomero M, Barbati C, Perricone C, Ceccarelli F, Finucci A, Celia AI, Currado D, Afeltra A, Schininà ME, Barnaba V, Conti F, Valesini G, Alessandri C. Homocysteinylated alpha 1 antitrypsin as an antigenic target of autoantibodies in seronegative rheumatoid arthritis patients. J Autoimmun. 2020 Sep;113:102470.

[4]Wakefield RJ, Balint PV, Szkudlarek M, et al. Musculoskeletal ultrasound including definitions for ultrasonographic pathology. J Rheumatol 2005; 32: 2485-2487.

Disclosure of Interests

None declared.

AB0118 PORPHYROMONAS GINGIVALIS AMOUNT IN THE TONGUE BIOFILM IS ASSOCIATED WITH EROSIVE ARTHRITIS IN SYSTEMIC LUPUS ERYTHEMATOSUS

Background

Several data have demonstrated the occurrence of erosive arthritis in Systemic Lupus Erythematosus (SLE) patients. However, few studies have focused on the pathogenic mechanisms involved in this feature. The implication of oral pathogens has been proved in Rheumatoid Arthritis: in particular, Porphyromonas gingivalis (Pg), by inducing citrullination, could trigger autoimmune response.

Objectives

We evaluated amount of Pg of the tongue in a cohort of SLE patients with arthritis, focusing on the association with the erosive phenotype.

Methods

SLE patients with arthritis were enrolled. We evaluated the presence of ACPA and RF by using commercially enzyme-linked immunosorbent assay kits. SLEDAI-2k was applied to assess disease activity and DAS28 to assess joint inflammatory status. Erosive damage was evaluated by ultrasound at level of metacarpophalangeal and proximal interphalangeals joints. All subjects underwent a tongue cytologic swab in order to quantify the amount of Pg (real-time PCR). The bacterium expression was obtained from the ratio between the patient’s DNA amount and that obtained from healthy subjects.

Results

The present analysis included 33 SLE patients (M/F 3/30; median age 47 years, IQR 17; median disease duration 216 months, IQR 180). Concerning activity at the time of the enrollment, we found a median DAS28 value of 3.8 (IQR 2.8) and a median SLEDAI-2k of 4 (IQR 5). Twelve patients (36.4%) showed US-detected erosive damage in at least one joint, significantly associated with ACPA positivity (p<0.0001). Furthermore, patients with erosive damage showed significantly higher median DAS28 values in comparison with those without [4 (IQR 3.1) versus 3.2 (IQR 2.1), p=0.03]. Moving on the oral pathogen analysis, we found a mean Pg ratio of 19.7±31.1 (median 6.6, IQR 22.3). When dividing patients according to the presence of erosive damage, we found higher Pg amount in SLE patients with this phenotype in comparison with those without (31.4±44.3 versus 12.9±19.2, p=ns; Figure 1A). Thus, we used Pg mean values as threshold, identifying two groups of patients, namely highPg and lowPg. In a receiver operating characteristic curve analysis (ROC), this threshold resulted in the most sensitive and specific one (sensitivity of 85%; specificity of 50%). As reported in Figure 1B, erosive damage was significantly more frequent in highPg patients in comparison with lowPg (60.0% versus 26.0%, p=0.001). Furthermore, highPg patients showed higher prevalence of skin manifestations, serositis and neurological involvement compared to lowPg patients (p=0.005, p=0.03, p=0.0001, respectively).

Conclusion

The possible contribution of oral microbiota in SLE erosive arthritis was here evaluated for the first time, finding a significant association between erosive damage and higher expression of Pg at tongue level.

Disclosure of Interests

None declared

AB0119 ROLE OF COSTIMULATORY MOLECULES IN SYSTEMIC LUPUS ERYTHEMATOSUS: FOCUS ON CD137

Background

Systemic Lupus Erythematosus (SLE) is a chronic autoimmune disease characterized by a wide autoantibodies production. The traditionally concept of a B-cell driven disease has been changed in the last years due to the evidence demonstrating the crucial role of T cells in SLE pathogenesis. In particular, regulatory (Treg) and memory T cells seem act through co-stimulatory and co-inhibitory molecules, such as CD137, PD1-1 and CTLA4. The over-expression of this molecules on lymphocytes may contribute to immune system dysregulation.

Objectives

The primary objective of the present case-control study was to evaluate the expression of CD137, PD1-1 and CTLA4 on T cell surface of SLE patients by using flow-cytometry. Secondly, we evaluated the percentage of Treg and memory T cells.

Methods

We enrolled patients SLE patients (2019 ACR/EULAR criteria) and sex/age-matched healthy subjects (HS). Demographic, clinical, and laboratory data were collected in a standardized computerized electronically filled form. Disease activity was assessed by SLEDAI-2k. Each subject underwent peripheral blood sample collection. By using flow-cytometry we evaluated the expression of FOXP3, CD137, PD1-1 and CTLA4, CD45, CD25, CCR7 to determine the percentage of Treg and memory T cells.

Results

The present analysis included 21 SLE patients [M/F 1/20 median age 48 years (IQR 17), median disease duration 144 months (IQR 204)]. The Treg percentage was significantly lower in SLE compared to HS [median 4.2 (IQR 0.32) versus 2.5 (IQR 2.44); p=0.001, Figure 1A]. Moving on effector Treg (eTreg), SLE patients with high disease activity (SLEDAI > 4) showed a significantly higher prevalence for these cells compared to patients with SLEDAI ≤ 4 [1.16 (IQR 0.51) versus 0.53 (IQR 0.8), p=0.014, Figure 1B]. Moreover, inverse correlation was found between eTreg percentage and SLEDAI-2k [p=0.029, r=-0.47 (CI 0.75 – 0.04) Figure 1C]. The evaluation of CD137 expression was significantly higher in SLE patients compared to HS on CD3+ cells [median 5.32 (IQR 6.11) versus 3.3 (IQR 1.7), p=0.001, Figure 1F]. On CD4+ cells, CD137 expression positively correlated with disease activity [p=0.0082, r=0.58 (CI 0.15-0.82)]. Finally, when analysing memory T cells subpopulations, inverse correlation has been found between effector memory T cells (TEM, CD45RA-CCR7-) and SLEDAI-2k when considering CD3+ [p=0.029, r=-0.56 (CI 0.81 – 0.12)] and CD4+ cells [p=0.016, R=-0.54 (CI -0.80 - -0.1)]. Of note, CD137 expression on T central memory cells (TCM, CD45RA-CCR7+) positively correlated with SLEDAI-2k [(p=0.019, r=0.52 (CI 0.09 – 0.79)].

Figure 1.

A) Comparison of the percentage of Treg in HS and SLE patients. B) Comparison of the percentage of eTreg in SLE patients with high disease activity and low disease activity C) Correlation between % eTreg and SLEDAI-2k. D) Comparison of the percentage of CD3+CD137+ cells in HS and SLE patients. E) Comparison of % of CD4+CD137+ cells in SLE patients with high disease activity and low disease activity F) Correlation between % of CD4+CD137+ cells and SLEDAI-2k.

Conclusion

Our results suggest a possible role of CD137-CD137L axis in SLE pathogenesis. The stimulatory role of this molecule is indicated by the positive correlation between SLEDAI-2k values and surface expression of CD137. Moreover, inverse correlation between SLEDAI-2k and eTreg percentage suggests a possible Treg dysregulation in SLE.

Table 1.

SLE cohort features

Clinical and Laboratory FeaturesMucocutaneous80.9%Articular76.1%Serositis19.0%Kidney23.8%Haematological48.2%CNS/PNS9.5%Thrombotic events4.7%anti-dsDNA68.4%anti-SSA/anti-SSB47.6%anti-RNP19.0%anti-Sm33.0%Antiphospholipid antibodies14.2%Low C3/C457.1%Previous TherapyGlucocorticoid90.5%Hydroxychloroquine95.2%Methotrexate23.8%Mofetil Mycophenolate33.3%Ciclosporin28.5%Cyclophosphamide9.5%Azathioprine33.3%Rituximab14.3%Antiplatelet23.8%Anticoagulant therapy4.7%

Disclosure of Interests

None declared

P44 PREDICTORS OF MORTALITY AFTER ACUTE TYPE A AORTIC DISSECTION REPAIR IN PATIENTS OF 70 YEARS OF AGE OR OLDER

Objectives

The impact of age on outcomes of acute type A aortic dissection remains controversial. We sought to investigate 30–day and follow–up outcomes of acute type A aortic dissection repair in elderly patients. Survival anlysis was performed and independent risk factors for mortality were searched.

Methods

During a 21–year period (2000–2021), 102 patients of 70 years of age or older were emergently treated for acute type A aortic dissection at our institution. (mean age 75.1 ± 3.8 years, 53.9% male) Preoperative characteristics are displayed in Table I.

Results

Overall 30–day mortality (including operative mortality) was 21.6%. Mortality increased among patients presenting with atrial fibrillation (adjusted odds ratio 10.33, P = 0.02) and visceral malperfution (adjusted odds ratio 70.88, P = 0.005). Survival at 1, 5 and 10 years was 70.2 ± 4.6%, 50.9 ± 5.6% and 24.1 ± 5.6%, respectively (Figure 1). The need to perform concomitant coronary artery bypass grafting was the only independent risk factor for mortality during follow–up. (adjusted odds ratio 2.21, P = 0.04)

Conclusions

Thirty –day and follow–up mortality were extremely satisfactory in elderly patients undergoing acute type A dissection repair. We could detect significant disease and surgery–related risk factors for death. Patients presenting with atrial fibrillation or visceral malperfusion had the poorest 30–day outcome. The need to perform concomitant coronary artery bypass grafting, significantly increased the mortality during follow–up.

The diagnostic challenge of mild citrulline elevation at newborn screening

Citrulline is a target analyte measured at expanded newborn screening (NBS) and its elevation represents a biomarker for distal urea cycle disorders and citrin deficiency. Altered ratios of citrulline with other urea cycle-related amino acids are helpful for the differential diagnosis. However, the use of cut-off values in screening programmes has raised the issue about the interpretation of mild elevation of citrulline levels detected at NBS, below the usual range observed in the "classical/severe" forms of distal urea cycle disorders and in citrin deficiency. Herein, we report ten subjects with positive NBS for a mild elevation of citrulline (<100 μmol/L), in whom molecular investigations revealed carriers status for argininosuccinate synthase deficiency, a milder form of argininosuccinate lyase deficiency and two other diseases, lysinuric protein intolerance and dihydrolipoamide dehydrogenase deficiency, not primarily affecting the urea cycle. To guide the diagnostic process, we have designed an algorithm for mild citrulline elevation (<100 μmol/L) at NBS, which expands the list of disorders to be included in the differential diagnosis.

Determination of the valence band edge of Fe oxide nanoparticles dispersed in aqueous solution through resonant photoelectron spectroscopy from a liquid microjet

We use X-ray photoemission and a near ambient pressure with a liquid microjet setup to investigate the electronic structure of FeOOH nanoparticles dispersed in aqueous solution. In particular, we show that by using X-ray resonant photoemission in dilute solutions, we can overcome the limits of conventional photoemission such as low nanoparticle-to-solvent signal ratio, and local nanoparticle charging and measure the valence band structure of FeOOH nanoparticles in aqueous solution with chemical specificity. The resonant photoemission signal across the Fe 2p_3/2 absorption edge is measured for 2 wt% aqueous solutions of FeOOH nanoparticles (NPs) and the valence band maximum (VBM) of the hydrated FeOOH nanoparticles is determined. We compare the obtained VBM value in aqueous solution to that of FeOOH NPs in the dry phase. We show that the valence band edge position of NPs in the liquid phase can be accurately predicted from the values obtained in the dry phase provided that a simple potential shift due to solution chemistry is applied. Our results demonstrate the suitability of resonant photoemission in measuring the electronic structure of strongly diluted nanosystems where the conventional non-resonant photoemission technique fails.

POS0685 MYCOPHENOLATE MOFETIL IN SYSTEMIC LUPUS ERYTHEMATOSUS PATIENTS: FIVE-YEARS DRUG SURVIVAL IN RENAL AND NON-RENAL INVOLVEMENT

Background:

The updated EULAR recommendations for the management of systemic lupus erythematosus (SLE) underline the use of Mycophenolate Mofetil (MMF) in the treatment of different disease related manifestations (1). Several randomized controlled trials have demonstrated the efficacy of MMF in lupus nephritis (LN) patients but only case series and open-labelled trials have analyzed the use of this drug in other than LN features. Moreover, no data are available about the MMF retention rate in a real-life setting.

Objectives:

The present study aims at evaluating the 5-years drug retention rate (DRR) of MMF in a large monocentric SLE cohort. Secondly, we investigated the influence of MMF in disease activity changes and chronic damage progression.

Methods:

We performed a longitudinal study including all the SLE patients (ACR 1997 criteria) starting MMF treatment in our Lupus Clinic. Data about indications, mean dosage, duration of treatment and reasons for drug withdrawal were registered. The DRR was estimated using the Kaplan–Meier method. Disease activity and chronic damage were assessed by SLE Disease Activity Index 2000 (SLEDAI-2K) and SLICC Damage Index (SDI), respectively.

Results:

The present analysis included 162 SLE patients (M/F 22/140, median age at the disease diagnosis 25.5 years, IQR 13). At the beginning of MMF treatment, we registered a median age of 34 months (IQR 21) and a median disease duration of 72 months (IQR 123). The most frequent indications for prescribing MMF were LN (101 patients, 62.3%) and musculoskeletal manifestations (39, 24.1%), followed by neuropsychiatric involvement (10, 6.2%), and others disease related manifestations (12, 7.4%; in particular skin involvement, hematological features, myositis, vasculitis). MMF was administered at a mean daily dosage of 2.1±0.6 grams; no differences in dosage were found between the different indications (p=ns).

At the longitudinal analysis, we registered a median treatment duration of 30 months (IQR 55). Figure 1 reported data about DRR: in particular, at 60 months follow-up we observed a DRR of 61.1% for LN patients, which was similar to that registered for patients without renal involvement (NLN) (60.5%; p=ns). Interestingly, the DRR at 60 months was higher in the subgroup of patients treated for joint involvement (75.4%), even without reaching a statistically significant difference. During the observation period, 92 patients (59.2%) discontinued MMF (median treatment duration at discontinuation 25 months, IQR 35). Interestingly, the main cause of withdrawal was the achievement of persistent remission, observed in 20 patients (21.7%), followed by loss of efficacy (19 patients, 20.5%), drug intolerance and pregnancy planning (17 patients for both reasons, 18,4%). Furthermore, our analysis confirmed MMF efficacy, as demonstrated by the significant reduction in SLEDAI-2k values after 4, 12 and 24 months of treatment (p< 0.0001 for all the time-points in comparison with baseline). In addition, MMF resulted able to control chronic damage progression, as demonstrated by the lack of significant increase in SDI values (baseline: 0.6, IQR 1; last observation: 0.93, IQR 1; p=ns).

Conclusion:

The evaluation of a large SLE cohort demonstrated a good retention rate for MMF. In particular, our results demonstrated that MMF is also a safe and effective drug for SLE manifestation other than LN, in particular for joint involvement. Moreover, it is able to control disease activity and to prevent the progression of chronic damage.

References:

[1]Fanouriakis A et al. Ann Rheum Dis. 2019 Jun;78(6):736-745.

Disclosure of Interests:

None declared

AB0087 AUTOANTIBODIES DIRECTED AGAINST HOMOCYSTEINYLATED ALPHA 1 ANTITRYPSIN AS A POTENTIAL NEW BIOMARKER FOR ARTHRITIS IN PATIENTS AFFECTED BY SYSTEMIC LUPUS ERYTHEMATOSUS

Background:

Joint involvement represents one of the most frequent features in patients affected by Systemic Lupus Erythematosus (SLE). This manifestation is characterized by a great heterogeneity in phenotype and severity: the application of more sensitive imaging techniques identified an erosive damage in about 25% of patients (1). This damage has been associated with autoantibodies, such as anti-citrullinated (ACPA) and anti-carbamylated proteins (antiCarP), previously identified in patients Rheumatoid Arthritis (RA) patients. Recently, homocysteinylated alpha 1 antitrypsin (Hcy-1A1AT) has been identified as a new antigenic target of autoantibodies in seronegative RA patients: in detail, anti-homocysteinylated alpha 1 antitrypsin (anti – HATA) antibodies have been identified in 75.7% of patients (2).

Objectives:

In the present study, we aimed at determining the prevalence of anti – HATA in a cohort of SLE patients.

Methods:

We evaluated patients affected by SLE according to the 1997 ACR criteria. Demographic, clinical, and laboratory data were collected in a standardized computerized electronically filled form. Each subject underwent peripheral blood sample collection. Hcy-A1AT was obtained by in vitro modification of native A1AT and used as antigens by ELISA to test the presence of anti–HATA in sera obtained from enrolled subjects. Finally, we investigated the presence of ACPA and Rheumatoid Factor (RF) commercial ELISA kits and of anti-CarP (home-made ELISA) by a home-made ELISA in SLE patients’ sera. As control, we enrolled 40 patients affected by Osteoarthritis (OA) and 41 healthy subjects (HS).

Results:

The present analysis included 88 SLE patients (M/F 6/82 median age 47 years (IQR 17), median disease duration 156 months (IQR 180). Joint involvement was observed in 75 SLE patients (85.2%): in detail, 65 patients referred arthritis and the remaining 10 inflammatory arthralgias. We identified the presence of anti–HATA IgG in 38 SLE patients (43.2%). This prevalence was significantly higher in comparison with OA and HS subjects [15.0% (p<0.001) and 0% (p<0.0001), respectively; Figure 1A]. Focusing on the SLE cohort, no differences were observed between patients with and without joint involvement in anti–HATA IgG prevalence (41.3% versus 34.7%, respectively; p=0.34). However considering SLE patients according to the presence of arthralgia and arthritis, the prevalence of anti-HATA was significantly higher in patients with arthritis in comparison with those patients with arthralgias (46.1% versus 11.1%, p=0.02; figure 1B). Finally, no significant association between anti-HATA and the other tested autoantibodies (RF, ACPA, anti-CarP) was found.

Conclusion:

We evaluated the prevalence of anti-HATA in a cohort of SLE patients. The prevalence of these autoantibodies was significantly higher in SLE patients than in OA patients and in HS. The association with arthritis suggests a possible role for anti-HATA as biomarkers of SLE-related joint involvement.

References:

[1]Ceccarelli F. Perricone C. Cipriano E. et al. Joint involvement in systemic lupus erythematosus: From pathogenesis to clinical assessment. Seminar in Arthritis and Rheumatism, 47(1), 53 – 64.

[2]Colasanti T. Sabatinelli D. Mancone et al. Homocysteinylated alpha 1 antitrypsin as an antigenic target of autoantibodies in seronegative rheumatoid arthritis patients. Journal of Autoimmunity 2020 Sep;113:102470.

Disclosure of Interests:

None declared

Ethylmalonic encephalopathy and liver transplantation: long-term outcome of the first treated patient

Background

Ethylmalonic encephalopathy (EE) is a severe intoxication-type metabolic disorder with multisystem clinical features and leading to early death. In 2014, based on the promising results obtained by liver-targeted gene therapy in Ethe1^−/− mouse model, we successfully attempted liver transplantation in a 9-month-old EE girl. Here we report her long-term follow-up, lasting over 6 years, with a comprehensive evaluation of clinical, instrumental and biochemical assessments.

Results

Neurological signs initially reverted, with a clinical stabilization during the entire follow-up course. Accordingly, gross motor functions improved and then stabilized. Psychomotor evaluations documented an increasing communicative intent, the acquisition of new social skills and the capability to carry out simple orders. Neurophysiological assessments, which included EEG, VEP/ERG and BAEPs, remained unchanged. Brain MRI also stabilized, showing no further lesions and cerebral atrophy improvement. Compared to pre-transplant assessments, urinary ethylmalonic acid strikingly reduced, and plasma thiosulphate fully normalized. The child maintained good clinical conditions and never experienced metabolic crises nor epileptic seizures.

Conclusions

The long-term follow-up of the first EE transplanted patient demonstrates that liver transplantation stabilizes, or even improves, disease course, therefore representing a potentially elective option especially in early-diagnosed patients, such as those detected by newborn screening, before irreversible neurological damage occurs.

Novel NDUFA12 variants are associated with isolated complex I defect and variable clinical manifestation

Isolated biochemical deficiency of mitochondrial complex I is the most frequent signature among mitochondrial diseases and is associated with a wide variety of clinical symptoms. Leigh syndrome represents the most frequent neuroradiological finding in patients with complex I defect and more than 80 monogenic causes have been involved in the disease. In this report, we describe seven patients from four unrelated families harboring novel NDUFA12 variants, with six of them presenting with Leigh syndrome. Molecular genetic characterization was performed using next-generation sequencing combined with the Sanger method. Biochemical and protein studies were achieved by enzymatic activities, blue native gel electrophoresis, and western blot analysis. All patients displayed novel homozygous mutations in the NDUFA12 gene, leading to the virtual absence of the corresponding protein. Surprisingly, despite the fact that in none of the analyzed patients, NDUFA12 protein was detected, they present a different onset and clinical course of the disease. Our report expands the array of genetic alterations in NDUFA12 and underlines phenotype variability associated with NDUFA12 defect.

A new UHPLC-MS/MS method for the screening of urinary oligosaccharides expands the detection of storage disorders

Background

Oligosaccharidoses are storage disorders due to enzymatic defects involved in the breakdown of the oligosaccharidic component of glycosylated proteins. The defect cause the accumulation of oligosaccharides (OS) and, depending on the lacking enzyme, results in characteristic profiles which are helpful for the diagnosis. We developed a new tandem mass spectrometry method for the screening of urinary OS which was applied to identify a large panel of storage disorders.

Methods

The method was set-up in urine and dried urine spots (DUS). Samples were analysed, without derivatization and using maltoheptaose as internal standard, by UHPLC-MS/MS with MRM acquisition of target OS transitions, including Glc4, the biomarker of Pompe disease. The chromatographic run was < 30 min. Samples from patients with known storage disorders were used for clinical validation.

Results

The method allowed to confirm the diagnosis of oligosaccharidoses (sialidosis, α-/β-mannosidosis, fucosidosis, aspartylglucosaminuria) and of GM1 and GM2 (Sandhoff type) gangliosidosis, by detecting specific OS profiles. In other storage disorders (mucolipidosis II and III, mucopolysaccharidosis type IVB) the analyisis revealed abnormal OS excretion with non-specific profiles. Besides Pompe disease, the tetrasaccharide Glc4 was increased also in disorders of autophagy (Vici syndrome, Yunis-Varon syndrome, and Danon disease) presenting cardiomuscular involvement with glycogen storage. Overall, results showed a clear separation between patients and controls, both in urine and in DUS.

Conclusion

This new UHPLC/MS-MS method, which is suitable for rapid and easy screening of OS in urine and DUS, expands the detection of storage disorders from oligosaccharidoses to other diseases, including the novel category of inherited disorders of autophagy.

Health-related quality of life in paediatric patients with intoxication-type inborn errors of metabolism: Analysis of an international data set

Acute intoxication-type inborn errors of metabolism (IT-IEM) such as urea cycle disorders and non-acute IT-IEM such as phenylketonuria have a major impact on paediatric patients' life. Patients have to adhere to a strict diet but may face neurocognitive impairment and - in acute diseases - metabolic decompensations nevertheless. Research on the subjective burden of IT-IEM remains sparse. Studies with appropriate sample sizes are needed to make valid statements about health-related quality of life (HrQoL) in children and adolescents with IT-IEM. Six international metabolic centres contributed self-reports and proxy reports of HrQoL (assessed with the Paediatric Quality of Life Inventory) to the final data set (n = 251 patients; age range 2.3-18.8 years). To compare HrQoL of the patient sample with norm data and between acute and non-acute IT-IEM, t tests were conducted. To examine the influence of child age, sex, diagnosis and current dietary treatment on HrQoL, multiple linear regression analyses were conducted. Self-reports and proxy reporst showed significantly lower HrQoL total scores for children with IT-IEM compared to healthy children. Current dietary treatment significantly predicted lower proxy reported total HrQoL. Children with non-acute IT-IEM reported significantly lower psychosocial health and emotional functioning than children with acute IT-IEM. The patient sample showed significantly impaired HrQoL and a diet regimen remains a risk factor for lower HrQoL. Differences in HrQoL between acute and non-acute IT-IEM subgroups indicate that factors beyond symptom severity determine the perception of disease burden. Identifying these factors is of crucial importance to develop and implement appropriate interventions for those in need.

Plasma methylcitric acid and its correlations with other disease biomarkers: The impact in the follow up of patients with propionic and methylmalonic acidemia

Methylcitric acid (MCA) analysis has been mainly utilized for the diagnosis of propionate disorders or as a second-tier test in newborn screening, but its utility for patients monitoring still needs to be established. We explored the potential contribution of MCA in the long-term management of organic acidurias. We prospectively evaluated plasma MCA and its relationship with disease biomarkers, clinical status, and disease burden in 22 patients, 13 with propionic acidemia (PA) and nine with methylmalonic acidemia (MMA) on standard treatment and/or after transplantation. Samples were collected at scheduled routine controls or during episodes of metabolic decompensation (MD), 10 patients were evaluated after transplantation (six liver, two combined liver and kidney, 2 kidney). MCA levels were higher in PA compared to MMA and its levels were not influenced by the clinical status (MD vs well state). In MMA, MCA was higher in elder patients and, along with fibroblast growth factor 21 (FGF21) and plasma methylmalonic acid, negatively correlated with GFR. In both diseases, MCA correlated with ammonia, glycine, lysine, C3, and the C3/C2, C3/C16 ratios. The disease burden showed a direct correlation with MCA and FGF21, for both diseases. All transplanted patients showed a significant reduction of MCA in comparison to baseline values, with some differences dependent on the type of transplantation. Our study provided new insights in understanding the disease pathophysiology, showing similarities between MCA and FGF21 in predicting disease burden, long-term complications and in evaluating the impact of organ transplantation.

Early visual and neuro-development in preterm infants with and without retinopathy

BACKGROUND

Retinopathy of prematurity (ROP) is often associated with visual impairment and multiple developmental disabilities.

AIMS

As most of the previous studies include infants with brain lesions, that can determine visual impairment per se, a cohort of low neurological risk preterm infants without ROP and with various degree of severity of ROP was assessed in order to establish visual and neurodevelopmental outcome.

STUDY DESIGN

Preterm infants born at <31 weeks gestation, without major brain lesions, underwent visual function assessment at 1 year corrected age and neurodevelopmental assessment at 2 years corrected age.

SUBJECTS

One hundred and five infants were included in the study: 42 infants did not develop ROP, 7 reached stage 1 in zone 2 ROP, 37 reached prethreshold (untreated) type 2 ROP. The remaining 19 infants were classified as type 1 ROP.

OUTCOME MEASURES

Visual function (including fixing, tracking, visual acuity, visual field, attention at distance and nystagmus) were assessed at 12 months corrected age and Griffiths Scales at 2 years corrected age.

RESULTS

The severity of ROP was strongly correlated (p < 0.001) with both visual function at 1 year and neurodevelopment at 2 years. Similarly, the presence of nystagmus was also strongly correlated with visual and neurodevelopmental sequelae.

CONCLUSIONS

Infants with no or milder retinopathy showed normal visual function at 1 year and neurodevelopment at 2 years. Infants who underwent treatment more frequently showed abnormal results on several aspects of visual function. Presence of nystagmus appeared to increase the risk for abnormal visual function and neurodevelopmental outcome.

THU0627-HPR JOINT INVOLVEMENT SIGNIFICANTLY INFLUENCES QUALITY OF LIFE OF PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS

Background:

Joint involvement is one of the most common features observed in Systemic Lupus Erythematosus (SLE), potentially involving up to 90% of patients [1]. Several patients’ reported outcomes (PROs) have been employed to measure Quality of life (QoL) in SLE patients, but frequently not specifically developed for SLE patients. More recently, the LupusQoL has been validated, a disease specific questionnaire[2,3].

Objectives:

We focused at assessing the relationship between musculoskeletal manifestations and QoL in a large SLE cohort, by using the LupusQoL.

Methods:

SLE patients with a clinical history of joint involvement (arthralgia/arthritis – group A) were enrolled in the present study. SLE diagnosis was performed according to the revised 1997 ACR criteria. As a control group, we enrolled SLE patients without history of joint involvement (group B).Disease activity was assessed by the SLE Disease Activity Index-2000 (SLEDAI-2k). The activity of joint involvement was assessed by using the disease activity score on 28 joints (DAS28ESR). The LupusQoL was administered to the enrolled patients (Group A and Group B). It consists of 34 items referring to eight domains: physical health (PH), pain (P), planning (PL), intimate relationships (IR), burden to others (BO), emotional health (EH), body image (BI) and fatigue (F).

Results:

Group A included 110 patients [M/F 8/102; median age 49 years (IQR 13), median disease duration 156 months (IQR 216)], while group B included 58 patients [M/F 11/47; median age 40 years (IQR 15), median disease duration 84 months (IQR 108)]. Group A showed a significantly lower disease duration and mean age in comparison with group B (P< 0.001 for both comparisons). As represented in figure 1, group A showed significantly lower values in all LupusQoL domains except for “burden to others” domain. Moreover, we observed an inverse correlation between DAS28ESRand all the LupusQoL domains in group A patients [PH (r=-0.5, P>0.0001), P (r=-0.5, P<0.0001), PL (r=-0.5, P<0.0001), IR (r=-0.2, P=0.006), BO (r=-0.4, P=0.0004), EH (r=-0.3, P=0.0009), BI (r=-0.4, P=0.001), F (r=-0.4, P<0.0001)]. Conversely, SLEDAI-2k values inversely correlated only with PL (r=-0.3, P=0.006), IR (r=-0.25, P=0.02), EH (r=-0.3, P=0.02).

Figure 1.

Conclusion:

In the present study, by using a disease specific PRO, we found a poorer QoL in SLE patients with joint involvement in comparison with those without this manifestation. Moreover,DAS28ESRsignificantly correlated with all LupusQol domains, differently from SLEDAI-2k, suggesting the need to evaluate joint involvement with a specific activity index.

References:

[1]Cervera R et al. Medicine 1993

[2]McElhone K. et al. Arthritis Rheum 2007.

[3]Conti F et al. Lupus 2014

Group (A)Group (B)pPH80,38 ± 21,4362,88 ± 23.28< 0.0001P82,36 ± 25.0862,30± 26.02< 0.0001PL83,04 ± 27.8270,58± 29.450.001IR84,49± 25.9965,36± 36.330.0005BO69,58 ± 28.4663,45± 28.950.129EH71,98 ± 24.6964,69± 23.050.0169F73,69 ± 24.2959,78±26.060.0004B78,14 ± 24.6156,28±30.14<0.0001

Disclosure of Interests:

Francesco Natalucci: None declared, Fulvia Ceccarelli: None declared, enrica cipriano: None declared, Giulio Olivieri: None declared, Carlo Perricone: None declared, Francesca Romana Spinelli Grant/research support from: Pfizer, Consultant of: Novartis, Gilead, Lilly, Sanofi, Celgene, Speakers bureau: Lilly, Simona Truglia: None declared, Francesca Miranda: None declared, cristiano alessandri Grant/research support from: Pfizer, fabrizio conti Speakers bureau: BMS, Lilly, Abbvie, Pfizer, Sanofi, Guido Valesini: None declared

THU0227 CAFFEINE INTAKE MODULATES DISEASE ACTIVITY AND CYTOKINES LEVELS IN SYSTEMIC LUPUS ERYTHEMATOSUS PATIENTS

Background:

Systemic lupus erythematosus (SLE) is an autoimmune disease mainly affecting women of childbearing age. The interplay between genetic and environmental factors may contribute to disease pathogenesis1. At today, no robust data are available about the possible contribute of diet in SLE. Caffeine, one of the most widely consumed products in the world, seems to interact with multiple components of the immune system by acting as a non-specific phosphodiesterase inhibitor2.In vitrodose-dependent treatment with caffeine seems to down-regulate mRNA levels of key inflammation-related genes and similarly reduce levels of different pro-inflammatory cytokines3.

Objectives:

We evaluated the impact of caffeine consumption on SLE-related disease phenotype and activity, in terms of clinimetric assessment and cytokines levels.

Methods:

We performed a cross-sectional study, enrolling consecutive patients and reporting their clinical and laboratory data. Disease activity was assessed by SLE Disease Activity Index 2000 (SLEDAI-2k)4. Caffeine intake was evaluated by a 7-day food frequency questionnaire, including all the main sources of caffeine. As previously reported, patients were divided in four groups according to the daily caffeine intake: <29.1 mg/day (group 1), 29.2-153.7 mg/day (group 2), 153.8-376.5 mg/day (group 3) and >376.6 mg/day (group 4)5. At the end of questionnaire filling, blood samples were collected from each patient to assess cytokines levels. These were assessed by using a panel by Bio-Plex assays to measure the levels of IL-6, IL-10, IL-17, IL-27, IFN-γ, IFN-α and Blys.

Results:

We enrolled 89 SLE patients (F/M 87/2, median age 46 years, IQR 14; median disease duration 144 months, IQR 150). The median intake of caffeine was 195 mg/day (IQR 160.5). At the time of the enrollment, 8 patients (8.9%) referred a caffeine intake < 29.1 mg/day (group 1), 27 patients (30.3%) between 29.2 and 153.7 mg/day (group 2), 45 patients (51%) between 153.8 and 376.5 mg/day (group 3) and 9 patients (10.1%) >376.6 mg/day (group 4). A negative correlation between the levels of caffeine and disease activity, evaluated with SLEDAI-2K, was observed (p=0.01, r=-0.26). By comparing the four groups, a significant higher prevalence of lupus nephritis, neuropsychiatric involvement, haematological manifestations, hypocomplementemia and anti-dsDNA positivity was observed in patients with less intake of caffeine (figure 1 A-E). Furthermore, patients with less intake of caffeine showed a significant more frequent use of glucocorticoids [group 4: 22.2%,versusgroup 1 (50.0%, p=0.0001), group 2 (55.5%, p=0.0001), group 3 (40.0%, p=0.009)]. Moving on cytokines analysis, a negative correlation between daily caffeine consumption and serum level of IFNγ was found (p=0.03, r=-0.2) (figure 2A); furthermore, patients with more caffeine intake showed significant lower levels of IFNα (p=0.02, figure 2B), IL-17 (p=0.01, figure 2C) and IL-6 (p=0.003, figure 2D).

Conclusion:

This is the first report demonstrating the impact of caffeine on SLE disease activity status, as demonstrated by the inverse correlation between its intake and both SLEDAI-2k values and cytokines levels. Moreover, in our cohort, patients with less caffeine consumption seems to have a more severe disease phenotype, especially in terms of renal and neuropsychiatric involvement. Our results seem to suggest a possible immunoregulatory dose-dependent effect of caffeine, through the modulation of serum cytokine levels, as already suggested byin vitroanalysis.

References:

[1]Kaul et alNat. Rev. Dis. Prim.2016; 2. Aronsen et alEurop Joul of Pharm2014; 3. Iris et alClin Immun.2018; 4. Gladman et al J Rheumatol. 2002; 5. Mikuls et alArth Rheum2002

Disclosure of Interests:

Valeria Orefice: None declared, Fulvia Ceccarelli: None declared, cristiana barbati: None declared, Ramona Lucchetti: None declared, Giulio Olivieri: None declared, enrica cipriano: None declared, Francesco Natalucci: None declared, Carlo Perricone: None declared, Francesca Romana Spinelli Grant/research support from: Pfizer, Consultant of: Novartis, Gilead, Lilly, Sanofi, Celgene, Speakers bureau: Lilly, cristiano alessandri Grant/research support from: Pfizer, Guido Valesini: None declared, Fabrizio Conti Speakers bureau: BMS, Lilly, Abbvie, Pfizer, Sanofi

FRI0159 EROSIVE ARTHRITIS IN SYSTEMIC LUPUS ERYTHEMATOSUS: APPLICATION OF CLUSTER ANALYSIS

Background:

Systemic Lupus Erythematosus (SLE) related arthritis has been traditionally defined non-erosive and then considered a minor manifestation. Thanks to the application of more sensitive imaging techniques, such as ultrasonography (US), erosive damage has been identified in up to 40% of SLE patients with joint involvement, suggesting the need for more appropriate treatment (1). Antibodies directed against citrullinated and carbamilated proteins (ACPA and anti-CarP, respectively) have been associated with erosive damage and then proposed as biomarkers for this more aggressive phenotype (2).

Objectives:

Here, we evaluated a large SLE cohort with joint involvement by using cluster analysis, in order to identify the disease phenotype associated with erosive arthritis.

Methods:

For this analysis, we enrolled consecutive SLE patients (ACR 1997 criteria) with a clinical history of joint involvement (arthritis/arthralgia). Clinical and laboratory data were collected in a standardized computerized electronically filled form, including demographics, past medical history with the date of diagnosis, co-morbidities, previous and concomitant treatments, serological status. The presence of rheumatoid factor (RF), ACPA and anti-CarP was investigated by ELISA test. Erosive damage was assessed by ultrasonography at level of metacarpophalangeal, proximal interphalangeal and metatarsophalangeal joints (MyLab Eight Exp, Esaote, Florence, Italy). Data have been analysed by hierarchic cluster analysis (SPSS program, IBM).

Results:

We enrolled 203 patients [M/F 12/191, median age 46.0 years (IQR 18); median disease duration 120.0 months (IQR 108)]. Erosive damage was identified in 53 patients (26.1%), all of them referring at least one episode of arthritis during disease course. Moving on autoantibodies status, RF was positive in 29.5%, anti-CarP in 28.5% and ACPA in 11.2%. The univariate analysis demonstrated a significant association between US-detected erosive damage and anti-CarP (p=0.01), ACPA (p=0.03), and renal manifestations (p=0.03). In Figure 1 we reported the dendrogram obtained from cluster analysis, allowing the identification of four cluster. Positivity for ACPA, anti-CarP, erosive damage, Jaccoud’s arthropathy and renal manifestations were allocated in the same cluster. Interestingly, RF resulted allocated in a different cluster, including ENA, anti-SSA and anti-SSB antibodies.

Conclusion:

The application of cluster analysis allowed the identification of a specific SLE phenotype, characterized by erosive damage, renal manifestations and positivity for anti-CarP and ACPA. We could speculate about the presence of a shared pathogenic mechanism, involving NETosis, contributing to nephritis and erosive arthritis.

References:

[1]Ceccarelli F et al. Semin Arthritis Rheum 2017

[2]Ceccarelli F et al. Arthritis Res Ther 2018

Disclosure of Interests:

Fulvia Ceccarelli: None declared, Francesco Natalucci: None declared, Carlo Perricone: None declared, enrica cipriano: None declared, Carmelo Pirone: None declared, Giulio Olivieri: None declared, Tania Colasanti: None declared, Francesca Romana Spinelli Grant/research support from: Pfizer, Consultant of: Novartis, Gilead, Lilly, Sanofi, Celgene, Speakers bureau: Lilly, cristiano alessandri Grant/research support from: Pfizer, Guido Valesini: None declared, fabrizio conti Speakers bureau: BMS, Lilly, Abbvie, Pfizer, Sanofi

OP0204 LUPUS COMPREHENSIVE DISEASE CONTROL IN SYSTEMIC LUPUS ERYTHEMATOSUS PATIENTS: APPLICATION OF A NEW INDEX

Background:

The main outcomes in SLE patients management are represented by the remission achievement and chronic damage prevention. Even though activity and damage are intimately connected, to date indices including both these outcomes are not available.

Objectives:

In the present study, we aimed at assessing the application of a new index, the Lupus comprehensive disease control (LupusCDC), including disease activity and chronic damage progression.

Methods:

We performed a longitudinal analysis, including SLE patients according to ACR 1997 criteria, followed-up in the period between January 2014 and December 2018, and with at least one visit per year. Disease activity was assessed by SLE Disease Activity Index 2000 (SLEDAI-2K) and three different remission levels were evaluated, as reported in Table 1 (1).

Table 1.

Remission levels considered in the study (1).

Remission levelDefinitionComplete Remission(CR)No clinical and serological activity (SLEDAI-2K=0) in corticosteroid-free and immunosuppressant-free patients (antimalarials allowed)Clinical remission off-corticosteroids(ClR-GCoff)Serological activity with clinical quiescent disease according to SLEDAI-2K in corticosteroid-free patients (stable immunosuppressive therapy and antimalarials allowed)clinical remission on-corticosteroids(ClR-GCon)Clinical quiescent disease according to SLEDAI-2K in patients on prednisone 1–5 mg/day (stable immunosuppressants and antimalarials allowed)

Chronic damage was registered according to SLICC damage index (SDI). All the patients were evaluated at baseline (T0) and every 12 months (T1, T2, T3, T4). At each time-point, we calculated the prevalence of LupusCDC, defined as remission achievement plus absence of chronic damage progression in the previous one year. We calculated this outcome including separately the different remission levels.

Results:

According with inclusion criteria, 172 SLE patients were evaluated in the present analysis [M/F 16/156, median age 49 years (IQR 16.7), median disease duration 180 months (IQR 156)]. At first assessment, we observed a mean±SD SDI value of 0.7±1.1. In details, 56 patients (32.5%) showed damage in at least one organ/system and the presence of damage was significantly associated with age (p<0.0001, r=0.3) and disease duration (p=0.0003, r=0.3). During the follow-up, we observed a significant increase in SDI values compared with T0 (T1: mean±DS 0.8±1.3, p<0.0001; T2: 0.8±1.4, p<0.0001; T3: 0.9±1.4 p=0.0001; T4: 1.0±1.5 p<0.0001).

In figure 1A and 1B we reported the proportion of patients achieving the different levels of remission and LupusCDC, respectively. In particular, the LupusCDC definition including CR was the most frequently detected in all time-points evaluated (T1: 18.0%; T2: 31.9%; T3: 27.9%; T4: 24.4%), with a significant difference at T2 [LupusCDC(CR)versusLupusCDC(ClR-GCoff), p=0.0002; LupusCDC(CR)versusLupusCDC(ClR-GCon) p=0.0002)], T3 [LupusCDC(CR)versusLupusCDC(ClR-GCoff), p=0.03; LupusCDC(CR)versusLupusCDC(ClR-GCon) p=0.006], T4 [LupusCDC(CR)versusLupusCDC(ClR-GCon), p=0.002]. No significant differences were found when comparing the prevalence of different remission levels and the prevalence of LupusCDC including the corresponding remission.

Conclusion:

In the present analysis we proposed for the first time a new index including disease activity and chronic damage, in order to evaluate the proportion of SLE patients reaching a comprehensive disease control. We found that CR is most frequently associated with the absence of damage progression.

References:

[1]Zen M et al. Ann Rheum Dis 2017.

Disclosure of Interests:

Fulvia Ceccarelli: None declared, Giulio Olivieri: None declared, Lorenzo Dominici: None declared, Alessandra Ida Celia: None declared, enrica cipriano: None declared, Cristina Garufi: None declared, Silvia Mancuso: None declared, Francesco Natalucci: None declared, Valeria Orefice: None declared, Carlo Perricone: None declared, Carmelo Pirone: None declared, viviana antonella pacucci: None declared, Francesca Morello: None declared, Simona Truglia: None declared, Francesca Miranda: None declared, Francesca Romana Spinelli Grant/research support from: Pfizer, Consultant of: Novartis, Gilead, Lilly, Sanofi, Celgene, Speakers bureau: Lilly, cristiano alessandri Grant/research support from: Pfizer, fabrizio conti Speakers bureau: BMS, Lilly, Abbvie, Pfizer, Sanofi

Spinal cord demyelination in children: A diagnostic challenge in neuropaediatrics for a good outcome

BACKGROUND

Biotinidase deficiency (BTD) is an autosomal recessive inborn error of metabolism provoking progressive biotin depletion, which causes, in turn, multiple carboxylase deficiency. Its infantile onset is characterized by intractable seizures associated with lethargy, psychomotor regression, hypotonia, feeding and respiratory problems, and cutaneous abnormalities.

CASE DESCRIPTION

We describe a 52-month-old female whose clinical and neuroradiological pictures were consistent with myelopathy, which is generally more frequent in older patients, as well as with symptoms of an infantile onset of biotinidase deficiency, revealed at 17 months.

RESULTS

A biochemical biotinidase test revealed a profound deficiency of biotinidase detecting a 10% residual enzymatic activity, which led to the diagnosis of BTD. Gene sequencing revealed a compound heterozigous mutation (c.454A > C/c.1612C > T).

CONCLUSION

Our findings suggest that even if myelopathy is uncommonly reported in BTD, and generally occurs in older children, its presence in childhood-onset floppiness should always be considered as a possible marker for an atypical presentation of BTD. Although, until recently, BTD myelopathy was believed to be prevalent in older children, a spinal cord involvement has also been described in at least nine cases in early infancy. Thus, another early diagnosis suggests that myelopathy may be more frequent than previously thought, and it is probably underdiagnosed because spinal MRI is not always routinely performed on these children. Early recognition of BTD disease is important as it would lead to prompt treatment, preventing irreversible brain damage and increasing the chances of complete recovery.

THU0281 EXPLORING THE GENETIC DIVERSITY OF STAPHYLOCOCCUS AUREUS IN PATIENTS AFFECTED BY SYSTEMIC LUPUS ERYTHEMATOSUS: ASSOCIATION WITH DISEASE-RELATED FEATURES AND ACTIVITY

Background:

Infective factors play a central role in autoimmune diseases pathogenesis. It is possible to speculate that the host genotype could interact with genetic background of infective agents. We previously evaluated a large SLE cohort, observing the association between theS. Aureus(SA) carriage status and presence of a more active disease in terms of autoantibodies positivity.

Objectives:

We evaluated epidemiological, molecular characterization, genetic diversity and evolution of SA isolated from SLE patients by means of phylogenetic analysis.

Methods:

Consecutive SLE patients (ACR 1997 criteria) were enrolled: clinical/laboratory data were collected and nasal swab for SA identification was performed. On the basis of translation elongation factor (tuf) gene, a phylogenetic analysis was performed to investigate phylogenetic relationships and to assess significant clades in patients with persistent carriage status (nasal swab positive in two consecutive evaluation, performed 1 week apart). The first dataset was composed by seven SA tuf gene isolated from non-SLE individuals from different countries (downloaded from the GenBank database,https://www.ncbi.nlm.nih.gov/nucleotide/) and tuf gene SA collected from SLE patients enrolled in the present study.

Results:

We enrolled 118 patients (M/F 10/198; median age 45.5 years, IQR 13,2; median disease duration 120 months, IQR 144). Skin involvement is the most frequent disease manifestation (86 patients, 72.9%), followed by joint involvement (78 patients, 66.1%). Twenty-four patients (20.3%) were SA carriers (SA+), three of them resulted MRSA. SA+ patients showed a significantly higher prevalence of joint involvement (79.2%versus62.7%, P=0.01) and anti-dsDNA positivity (75.0%versus55.3%, P=0.004). Moreover, SA+ SLE showed a more active disease, in terms of SLEDAI-2k values [SA+: median 2 (IQR 3.75)versusSA-: median 0 (IQR 2), P=0.04). The phylogenetic analysis has been restricted on the 21 non-MRSA SA+ patients. The maximum likelihood phylogenetic tree of the first dataset revealed a statistically supported larger clade (A, N=17) and a smaller one (B, N=4; figure 1A). SLE patients located in the clade A showed a significantly higher prevalence of joint involvement (88.2%) in comparison with clade B (50.0%, P<0.0001) and SA- (62.7%, P<0.0001, figure 2B). Moreover, haematological manifestations were significantly more frequent in clade A patients (64.7%) compared with B (50.0%, P=0.004, figure 2C).

Conclusion:

The results of the present study confirmed the association between SA carriage status and disease activity, in terms of SLEDAI-2k values and anti-dsDNA positivity. The phylogenetic analysis ontufgene show a clustering ofSA+patients in two major clade (A and B). Interestingly thetufgenotype of clade A is significantly associated with a specific disease phenotype, characterized by joint involvement and positivity for anti-dsDNA. These findings support the hypothesis that bacterial genetic variants may be associated with specific disease features.

References:

[1]Rigante et al. Int J Mol Sci. 2015;

[2]Wertheim et al Lancet Infect Dis. 2005;

[3]Conti et al Arthritis Res Ther 2016;

[4]Tong et al Clin Microbiol Rev. 2015;

[5]Rhee et al Infect Control Hosp Epidemiol. 2015

Disclosure of Interests:

Giulio Olivieri: None declared, Fulvia Ceccarelli: None declared, Alessandra Lo Presti: None declared, silvia angeletti: None declared, Carlo Perricone: None declared, Giancarlo Iaiani: None declared, Lucia De Florio: None declared, francesca antonelli: None declared, Luigino Amori: None declared, Cristina Garufi: None declared, Francesca Romana Spinelli Grant/research support from: Pfizer, Speakers bureau: Lilly, BMS, Celgene, cristiano Alessandri: None declared, Guido Valesini: None declared, Massimo Cicozzi: None declared, Fabrizio Conti Speakers bureau: BMS, Lilly, Abbvie, Pfizer, Sanofi

Dravet syndrome: Early electroclinical findings and long-term outcome in adolescents and adults

To describe the outcome of Dravet syndrome (DS) in adolescents and adults we conducted a longitudinal retrospective study of two independent cohorts of 34 adolescents (group 1) and 50 adults (group 2). In both cohorts, we collected information about genetic mutation, and semiology of seizures at onset and during disease course. At the last evaluation, we considered the following features: epilepsy (distinguishing myoclonic/complete and nonmyoclonic/incomplete phenotype), neurologic signs, intellectual disability (ID), and behavioral disorders. Moreover, in both cohorts, we performed a correlation analysis between early characteristics of the disease and the outcome of DS with regard to seizure persistence, ID, behavioral disorder, and neurologic impairment at last evaluation. Group 1 includes 22 adolescents with complete form of DS and 12 with incomplete form; group 2 includes 35 adults with complete form and 15 with incomplete form. The seizures persisted in 73.6% of adolescents and in 80% of adults, but epilepsy severity progressively decreased through age. Seizure persistence correlated with the complete phenotype and with the occurrence of reflex seizures. At last evaluation, ID was moderate or severe in 70.5% of adolescents and in 80% of adults. The most severe cognitive and motor impairment was observed in patients with persisting seizures. The severity of cognition, language, and neurologic impairment at last evaluation correlated statistically with the complete phenotype. The study confirms that the global outcome of DS is poor in most cases, albeit epilepsy severity decreases throughout adulthood. The improvement of epilepsy throughout ages is not associated with improvement in intellectual abilities and motor skills; this confirms that the unfavorable outcome is not a pure consequence of epilepsy.

Effect of growth conditions on the efficiency of cell disruption of Neochloris oleoabundans

The impact of four different growth conditions on the cell disruption efficiency of Neochloris oleoabundans was investigated. A mechanical and biological cell disruption methods were evaluated separately and combined. It has been established that microalgae grown in marine water under nitrogen deprivation were the most resistant against cell disruption methods and released the lowest amount of proteins. The release of lipids, however, followed the "hindered molecule diffusion phenomenon" because it did not follow the same release pattern as proteins. The enzymatic treatment was efficient enough to release the majority of the proteins without combining it with high-pressure homogenization. Regarding energy input, Neochloris oleoabundans grown in marine water under nitrogen deprivation required the highest energy input to release proteins (E_p = 13.76 kWh.kg^-1) and to break the cells by high-pressure homogenization (E_{x - HPH} = 1.14 kWh.kg^-1) or by the combination of enzymes and High-pressure homogenization (E_{x - ENZ} = 2.79 kWh.kg^-1).

Early neurodevelopmental characterization in children with cobalamin C/defect

Cobalamin C (cblC) defect is the most common inherited disorder of cobalamin metabolism. Developmental delay, behavioral problems, and maculopathy are common, but they have not been systematically investigated. The aim of this study was to define early neurodevelopment in cblC patients and the possible contribution of different factors, such as mode of diagnosis, age at diagnosis, presence of brain lesions and epilepsy. Children up to the age of 4 years with a visual acuity ≥1/10 were evaluated using the Griffiths' Mental Development Scales. Eighteen children were enrolled (age range 12-48 months). Four were diagnosed by newborn screening (NBS); in the others mean age at diagnosis was 3.5 months (range 0.3-18 months). Eight had seizures: three in the first year, and five after the second year of life. Fourteen had brain lesions on magnetic resonance imaging (MRI). Neurovisual assessment evidenced low visual acuity (<3/10) in 4/18. NBS diagnosed patients had higher general and subquotients neurodevelopmental scores, normal brain MRI, and no epilepsy. The others showed a progressive reduction of the developmental quotient with age and language impairment, which was evident after 24 months of age. Our findings showed a progressive neurodevelopmental deterioration and a specific fall in language development after 24 months in cblC defect. The presence of brain lesions and epilepsy was associated with a worst neurodevelopmental outcome. NBS, avoiding major disease-related events and allowing an earlier treatment initiation, appeared to have a protective effect on the development of brain lesions and to promote a more favorable neurodevelopment.

Oxidative stress as a possible mechanism underlying multi-hormonal deficiency in chronic heart failure

OBJECTIVE

Chronic Heart Failure (CHF) is associated with multi-hormonal derangement depicting a prevalence of catabolic vs. anabolic axes. Moreover, thyroid adaption is characterized by the reduced conversion of thyroxine to the active hormone triiodothyronine. On the other hand, hormones modulate synthesis and utilization of antioxidant systems. Therefore, hormonal failure can cause unbalance between reactive radical species and the defenses, resulting in oxidative stress (OS). OS is well described in CHF, but the relationship with the hormonal picture is not entirely known. In the present review, we firstly analyze the mechanisms of ROS production in the heart, discussing animal and human studies, and focusing on new discovered protective mechanisms such as sirtuins and fibroblast growth factor 21 (FGF21). The second section is dedicated to the role of main anabolic axes influencing antioxidant systems. Finally, we present some data supporting the hypothesis that OS could be the link between hormonal derangement and clinical outcome of CHF.

Corticospinal tract damage in HHH syndrome: a metabolic cause of hereditary spastic paraplegia

BACKGROUND

Hyperornithinemia-hyperammonemia-homocitrullinuria (HHH) syndrome is a rare disorder of urea cycle characterized by progressive pyramidal and cerebellar dysfunction, whose pathophysiology is not yet fully understood. Here we describe the spectrum of the long fibers involvement in HHH syndrome, attempting a correlation between clinical, electrophysiological and neuro-radiological data.

METHODS

Nine HHH patients were longitudinally evaluated by clinical examination, neurophysiological assessment including motor (MEPs), somato-sensory evoked potentials (PESS) and nerve conduction velocity (NCV), brain and spinal cord MRI RESULTS: All patients had pyramidal dysfunction and 3/9 an overt spastic paraplegia. Mild to moderate cerebellar signs were found in 7/9, intellectual disability in 8/9. At lower limbs, MEPs resulted abnormal in 7/8 patients and PESS in 2/8; peripheral sensory-motor neuropathy was found in 1/9. MRI documented atrophic changes in supra-tentorial brain regions in 6/9 patients, cerebellum in 6/9, spinal cord in 3/7.

CONCLUSIONS

A predominant corticospinal dysfunction is evident in HHH syndrome, along with milder cerebellar signs, intellectual disability of variable degree and rare peripheral neuropathy. Phenotypical similarities with other disorders affecting the urea cycle (argininemia and pyrroline-5-carboxylate synthetase deficiency) suggest possible common mechanisms contributing in the maintenance of the corticospinal tract integrity. HHH syndrome phenotype largely overlaps with complex Hereditary Spastic Paraplegias (HSPs), in the list of which it should be included, emphasizing the importance to screen all the unsolved cases of HSPs for metabolic biomarkers.

Phenotype, treatment practice and outcome in the cobalamin-dependent remethylation disorders and MTHFR deficiency: Data from the E-HOD registry

AIM

To explore the clinical presentation, course, treatment and impact of early treatment in patients with remethylation disorders from the European Network and Registry for Homocystinurias and Methylation Defects (E-HOD) international web-based registry.

RESULTS

This review comprises 238 patients (cobalamin C defect n = 161; methylenetetrahydrofolate reductase deficiency n = 50; cobalamin G defect n = 11; cobalamin E defect n = 10; cobalamin D defect n = 5; and cobalamin J defect n = 1) from 47 centres for whom the E-HOD registry includes, as a minimum, data on medical history and enrolment visit. The duration of observation was 127 patient years. In 181 clinically diagnosed patients, the median age at presentation was 30 days (range 1 day to 42 years) and the median age at diagnosis was 3.7 months (range 3 days to 56 years). Seventy-five percent of pre-clinically diagnosed patients with cobalamin C disease became symptomatic within the first 15 days of life. Total homocysteine (tHcy), amino acids and urinary methylmalonic acid (MMA) were the most frequently assessed disease markers; confirmatory diagnostics were mainly molecular genetic studies. Remethylation disorders are multisystem diseases dominated by neurological and eye disease and failure to thrive. In this cohort, mortality, thromboembolic, psychiatric and renal disease were rarer than reported elsewhere. Early treatment correlates with lower overall morbidity but is less effective in preventing eye disease and cognitive impairment. The wide variation in treatment hampers the evaluation of particular therapeutic modalities.

CONCLUSION

Treatment improves the clinical course of remethylation disorders and reduces morbidity, especially if started early, but neurocognitive and eye symptoms are less responsive. Current treatment is highly variable. This study has the inevitable limitations of a retrospective, registry-based design.

Trigonal and Peritrigonal Lesions of the Lateral Ventricle: Presurgical Tractographic Planning and Clinic Outcome Evaluation

BACKGROUND

Surgery of lesions within the atrium of the lateral ventricle remains a challenging procedure because of the deep location and the relationship to vascular structures. The aim of this study was to determine the usefulness of tractography to evaluate the position of white matter tracts located along the course of the surgical access to trigonal and peritrigonal lesions.

METHODS

Diffusion tensor imaging (DTI) was acquired in 19 patients. All patients underwent surgical resection of brain tumors. Pre- and postoperative clinical conditions were evaluated by a neurosurgeon, using the Karnofsky Performance Status Scale. The corticospinal tract, optic radiation, and arcuate fasciculum were reconstructed because of their location close to the trigonal region. Two neurosurgeons were asked to assess the surgical approach with and without tractography.

RESULTS

According to the tractographic reconstructions, the surgical access was chosen from the middle temporal gyrus in 12 patients (63%) and the posterior parietal gyrus in 7 patients (37%), leading to an a priori change in the surgical approach in 14 patients (73%). Six patients (31%) showed new postsurgical transient symptoms, whereas in 2 patients (10%) the deficits were permanent. After 30 days, the Karnofsky Performance Status Scale evaluation showed an improvement or a substantial stability of symptoms in 90% of cases. In 2 patients, a worsening of 30% of clinical performance was appreciable.

CONCLUSIONS

The use of DTI in preoperative planning of trigonal and peritrigonal lesions may help in description of the best surgical approach for patient; this technique allows to reach the tumors, saving the white matter tracts, when it is possible.

Persistent Hypoglycemia in Children: Targeted Gene Panel Improves the Diagnosis of Hypoglycemia Due to Inborn Errors of Metabolism

OBJECTIVES

To evaluate the role of next generation sequencing in genetic diagnosis of pediatric patients with persistent hypoglycemia.

STUDY DESIGN

Sixty-four patients investigated through an extensive workup were divided in 3 diagnostic classes based on the likelihood of a genetic diagnosis: (1) single candidate gene (9/64); (2) multiple candidate genes (43/64); and (3) no candidate gene (12/64). Subsequently, patients were tested through a custom gene panel of 65 targeted genes, which included 5 disease categories: (1) hyperinsulinemic hypoglycemia, (2) fatty acid-oxidation defects and ketogenesis defects, (3) ketolysis defects, (4) glycogen storage diseases and other disorders of carbohydrate metabolism, and (5) mitochondrial disorders. Molecular data were compared with clinical and biochemical data.

RESULTS

A proven diagnosis was obtained in 78% of patients with suspicion for a single candidate gene, in 49% with multiple candidate genes, and in 33% with no candidate gene. The diagnostic yield was 48% for hyperinsulinemic hypoglycemia, 66% per fatty acid-oxidation and ketogenesis defects, 59% for glycogen storage diseases and other carbohydrate disorders, and 67% for mitochondrial disorders.

CONCLUSIONS

This approach provided a diagnosis in ~50% of patients in whom clinical and laboratory evaluation did not allow identification of a single candidate gene and a diagnosis was established in 33% of patients belonging to the no candidate gene class. Next generation sequencing technique is cost-effective compared with Sanger sequencing of multiple genes and represents a powerful tool for the diagnosis of inborn errors of metabolism presenting with persistent hypoglycemia.

CO oxidation activity of Pt, Zn and ZnPt nanocatalysts: a comparative study by in situ near-ambient pressure X-ray photoelectron spectroscopy

The investigation of nanocatalysts under ambient pressure by X-ray photoelectron spectroscopy gives access to a wealth of information on their chemical state under reaction conditions. Considering the paradigmatic CO oxidation reaction, a strong synergistic effect on CO catalytic oxidation was recently observed on a partly dewetted ZnO(0001)/Pt(111) single crystal surface. In order to bridge the material gap, we have examined whether this inverse metal/oxide catalytic effect could be transposed on supported ZnPt nanocatalysts deposited on rutile TiO2(110). Synchrotron radiation near-ambient pressure X-ray photoelectron spectroscopy (NAP-XPS) operated at 1 mbar of O2 : CO mixture (4 : 1) was used at a temperature range between room temperature and 450 K. To tackle the complexity of the problem, we have also studied the catalytic activity of nanoparticles (NPs) of the same size, consisting of pure Pt and Zn nanoparticles (NPs), for which, moreover, NAP-XPS studies are a novelty. The comparative approach shows that the CO oxidation process is markedly different for the pure Pt and pure Zn NPs. For pure Pt NPs, CO poisoned the metallic surfaces at low temperature at the onset of CO2 evolution. In contrast, the pure Zn NPs first oxidize into ZnO, and trap carbonates at low temperature. Then they start to release CO2 in the gas phase, at a critical temperature, while continuously producing it. The pure Zn NPs are also immune to support encapsulation. The bimetallic nanoparticle borrows some of its characteristics from its two parent metals. In fact, the ZnPt NP, although produced by the sequential deposition of platinum and zinc, is platinum-terminated below the temperature onset of CO oxidation and poisoned by CO. Above the CO oxidation onset, the nanoparticle becomes Zn-rich with a ZnO shell. Pure Pt and ZnPt NPs present a very similar activity towards CO oxidation, in contrast with what is reported in a single crystal study. The present study demonstrates the effectiveness of NAP-XPS in the study of complex catalytic processes at work on nanocatalysts under near-ambient pressures, and highlights once more the difficulty of transposing single crystal surface observations to the case of nanoobjects.

The urinary organic acids profile in single large-scale mitochondrial DNA deletion disorders

Single large-scale mitochondrial DNA deletions disorders are classified into three main phenotypes with frequent clinical overlap: Pearson marrow-pancreas syndrome (PMS), Kearns-Sayre syndrome (KSS) and chronic progressive external ophtalmoplegia (PEO). So far, only few anecdotal studies have reported on the urinary organic acids profile in this disease class. In this single-center retrospective study, we performed quantitative evaluation of urinary organic acids in a series of 15 pediatric patients, 7 with PMS and 8 with KSS. PMS patients showed an organic acids profile almost constantly altered, whereas KSS patients frequently presented with normal profiles. Lactate, 3-hydroxybutyrate, 3-hydroxyisobutyrate, fumarate, pyruvate, 2-hydroxybutyrate, 2-ethyl-3-hydroxypropionate, and 3-methylglutaconate represented the most frequent metabolites observed in PMS urine. We also found novel metabolites, 3-methylglutarate, tiglylglycine and 2-methyl-2,3-dihydroxybutyrate, so far never reported in this disease. Interestingly, patients with a disease onset as PMS evolving overtime into KSS phenotype, presented persistent and more pronounced alterations of organic acid signature than in patients with a pure KSS phenotype. Our study shows that the quantitative analysis of urinary organic acid profile represents a helpful tool for the diagnosis of PMS and for the differential diagnosis with other inherited diseases causing abnormal organic acidurias.

Quantitative ionization energies and work functions of aqueous solutions

Despite the ubiquitous nature of aqueous solutions across the chemical, biological and environmental sciences our experimental understanding of their electronic structure is rudimentary-qualitative at best. One of the most basic and seemingly straightforward properties of aqueous solutions-ionization energies-are (qualitatively) tabulated at the water-air interface for a mere handful of solutes, and the manner in which these results are obtained assume the aqueous solutions behave like a gas in the photoelectron experiment (where the vacuum levels of the aqueous solution and of the photoelectron analyzer are equilibrated). Here we report the experimental measure of a sizeable offset (ca. 0.6 eV) between the vacuum levels of an aqueous solution (0.05 M NaCl) and that of our photoelectron analyzer, indicating a breakdown of the gas-like vacuum level alignment assumption for the aqueous solution. By quantifying the vacuum level offset as a function of solution chemical composition our measurements enable, for the first time, quantitative determination of ionization energies in liquid solutions. These results reveal that the ionization energy of liquid water is not independent of the chemical composition of the solution as is usually inferred in the literature, a finding that has important ramifications as measured ionization energies are frequently used to validate theoretical models that posses the ability to provide microscopic insight not directly available by experiment. Finally, we derive the work function, or the electrochemical potential of the aqueous solution and show that it too varies with the chemical composition of the solution.

Biorefinery of the macroalgae Ulva lactuca: extraction of proteins and carbohydrates by mild disintegration

The effect of osmotic shock, enzymatic incubation, pulsed electric field, and high shear homogenization on the release of water-soluble proteins and carbohydrates from the green alga Ulva lactuca was investigated in this screening study. For osmotic shock, both temperature and incubation time had a significant influence on the release with an optimum at 30 °C for 24 h of incubation. For enzymatic incubation, pectinase demonstrated being the most promising enzyme for both protein and carbohydrate release. Pulsed electric field treatment was most optimal at an electric field strength of 7.5 kV cm^-1 with 0.05 ms pulses and a specific energy input relative to the released protein as low as 6.6 kWh kg_prot^-1. Regarding literature, this study reported the highest protein (~ 39%) and carbohydrate (~ 51%) yields of the four technologies using high shear homogenization. Additionally, an energy reduction up to 86% was achieved by applying a novel two-phase (macrostructure size reduction and cell disintegration) technique.

Energy consumption and water-soluble protein release by cell wall disruption of Nannochloropsis gaditana

Several cell disruption methods were tested on Nannochloropsis gaditana, to evaluate their efficiency in terms of cell disintegration, energy input and release of soluble proteins. High-pressure homogenization (HPH) and bead milling were the most efficient with >95% cell disintegration, ±50% (w/w) release of total proteins and low energy input (<0.5kWh.kg^-1_biomass). Enzymatic treatment required low energy input (<0.34kWh.kg^-1_biomass), but it only released ±35% protein (w/w). Pulsed Electric Field (PEF) was neither energy-efficient (10.44kWh.kg^-1_biomass) nor successful for protein release (only 10% proteins w/w) and cell disintegration. The release of proteins after applying HPH and bead milling always required less intensive operating conditions for cell disruption. The energy cost per unit of released protein ranged from 0.15-0.25 €.kg_Protein^-1 in case of HPH, and up to 2-20 €.kg_Protein^-1 in case of PEF.

Simulated photoelectron intensities at the aqueous solution-air interface for flat and cylindrical (microjet) geometries

Ion spatial distributions at the aqueous-air/vacuum interface are accessible by energy-dependent X-ray photoelectron spectroscopy (XPS). Here we quantify the difference between a flat surface and a cylindrical microjet in terms of the energy-dependent information depth of the XPS experiment and in terms of the simulated photoelectron intensities using solutions of pure water and of 1 mol L-1 NaI as examples.